Counseling in HIV Testing Programs
July 31, 2014

WHEREAS HIV test counseling refers to a set of HIV-specific procedures conducted in the context of HIV testing that focus on providing education to promote accurate understanding of a positive or negative HIV test result; assistance with information on available HIV treatment resources; emotional support and referral for psychological intervention as needed; and direction on making linkages to HIV care;

WHEREAS the prevention focus of the National HIV/AIDS Strategy (NHAS) specifies an emphasis on a test-and-treat strategy aimed at identifying individuals who are unaware of their HIV seropositive status via expanded HIV testing efforts and facilitating early engagement in care (Millett et al., 2010; Dieffenbach & Fauci, 2009);

WHEREAS recent findings demonstrating the role of HIV viral suppression in reducing HIV transmission (e.g., Cohen et al., 2011) have highlighted the potential for HIV treatment to reduce HIV incidence by ensuring that individuals living with HIV are receiving antiretroviral therapy, a strategy referred to broadly as HIV treatment as prevention (Garnett, Becker, & Bertozzi, 2012; Wood, Milloy, & Montaner, 2012);

WHEREAS treatment as prevention strategies are being ramped up in light of estimates suggesting that, among individuals living with HIV in the United States, only approximately 24% are receiving antiretroviral therapy and only approximately 19% are achieving viral suppression as reflected by an undetectable serum viral load (Gardner, McLees, Steiner, del Rio, & Burman, 2011);

WHEREAS treatment as prevention requires an increased focus on HIV testing, as an estimated 1 in 5 individuals in the United States living with HIV infection are unaware of their HIV seropositive status (Campsmith, Rhodes, Hall, & Green, 2010) and these individuals pose a greater risk for transmitting the virus than those who are aware of their HIV serostatus (Gardner et al., 2011; Pinkerton, Holtgrave, & Galletly, 2008);

WHEREAS in line with the focus on HIV treatment as prevention, a “test-and-treat strategy” has emerged with a focus on early diagnosis and treatment of HIV that incorporates public health strategies aiming to ensure the easy accessibility of HIV testing, such as offering HIV testing as part of routine visits in health clinics and hospitals, providing HIV testing in non-medical community settings, and self-administered home HIV testing;

WHEREAS HIV test counseling has historically been a key element of HIV testing programs, providing important information and prevention messages for individuals who receive a negative test result and serving a vital educative and emotional support function for individuals who test positive as well as guidance for linking these individuals to medical care;

WHEREAS Centers for Disease Control and Prevention (CDC) recommendations for HIV testing in health care settings underscore the importance of efforts to link those receiving a positive HIV test result to care (CDC, 2006);

WHEREAS efforts to make HIV testing accessible in order to promote early HIV diagnosis and linkage to care may inadvertently result in a reduced role for HIV test counseling in the context of the HIV testing process, particularly since clear guidelines and policies relative to the availability and role of HIV test counseling in the era of expanded HIV testing, including in-home testing, have yet to be elaborated;

WHEREAS complications relative to linkage to care following HIV testing, including individuals who become lost to follow-up after HIV testing, may attenuate the prevention benefits believed to be conferred by the test-and-treat model (Andrews, Wood, Bekker, Middlekoop, & Walensky, 2012);

WHEREAS HIV test counseling is a key part of ensuring the success of expanded HIV testing programs in the context of the test-and-treat model, including successful linkage to care, particularly given empirical evidence that HIV test counseling is effective in encouraging individuals who test positive for HIV disease to access medical care (Eichler, Ray, & del Rio, 2002),

WHEREAS given that barriers to HIV testing may be posed by such factors as institutional mistrust of medical systems, concerns about discrimination, stigma worries, lack of knowledge about HIV and its treatment, and fear of a positive test result (Hoyt et al., 2012; Schwarcz et al., 2011; Wallace, McLellan-Lemal, Harris, Townsend, & Miller, 2011), HIV test counseling provides an opportunity to assess and explore these concerns when present among those who decide to participate in HIV testing;

WHEREAS HIV test counseling provides essential information on how HIV testing works and how to interpret accurately the meaning and implications of a negative or positive HIV test result (Halkitis, Barton, and Blachman-Forshay, 2012; Siconolfi, Halkitis, Moeller, Barton, & Rodriguez, 2011);

WHEREAS HIV test counseling is a key educative tool for ensuring proper interpretation of a negative HIV test result, including the provision of information regarding the critical importance of continuing safer sex practices and the possible need for repeat HIV testing given that there is a several month window of time before a new infection can be detected by testing;

WHEREAS HIV test counseling offers a context for addressing psychological distress that may result from receiving a positive HIV test result, including providing information that may ameliorate distress and/or referral to emotional support resources and mental health services (Joseph et al., 2011);

WHEREAS in order to confer maximum benefit, HIV test counseling strategies must take into account the specific needs, concerns, and cultural values of diverse groups, including women (e.g., HIV testing in pregnancy; HIV disclosure and intimate partner violence), sexual minority individuals, youth, older adults, people from rural communities, immigrant populations, people with disabilities (e.g., hearing disabilities), incarcerated/previously incarcerated individuals, and individuals from diverse socioeconomic backgrounds (Groce et al., 2103; Hoyt et al., 2012; Siconolfi et al., 2011; Spielberg, Kurth, Gorbach, & Goldbaum, 2001; Winningham et al. 2008);

WHEREAS HIV test counseling as part of the HIV testing process is especially critical for persons who are living with a severe mental illness, with the expectation that a substantive proportion of individuals who receive a positive HIV test result under expanded testing programs also will evidence a premorbid severe mental illness in light of epidemiological findings showing a disproportionate HIV seroprevalence among these individuals (Meade & Sikkema, 2005);

WHEREAS there is evidence suggesting that individuals who receive a positive HIV test result often perceive that there is an insufficient focus on HIV test counseling, the provision of needed information in the testing process, and active linkage to care (Garland et al., 2011);

WHEREAS there is a need for specific training for current and prospective service providers that includes content knowledge on HIV, information on the historical and contemporary social and environmental context of HIV, and guidance for how to assess and address provider self-care needs;

WHEREAS there is a need for research to assess the role of HIV test counseling for optimizing the effectiveness of expanded HIV testing models, particularly as this relates to linkage to care in the context of the test-and-treat model;

WHEREAS psychology and psychological science are well positioned to contribute to the development, implementation, and evaluation of HIV test counseling strategies in the context of the evolving parameters of HIV testing through applications of theory, intervention, and research methods (Apanovich, McCarthy, & Salovey, 2003; Earl & Albarracín, 2007; Huebner et al., 2010);

THEREFORE anyone tested for HIV should have access to quality HIV counseling;

THEREFORE there is a need to examine carefully the HIV test counseling issues associated with the emergence of in-home HIV testing, and to develop guidelines and strategies for ensuring that HIV test counseling is accessible to users of in-home HIV testing;

THEREFORE deliberate attention should be paid to obtaining better understanding of the needs of service recipients and service providers, and the dissemination of information and interventions to assist service providers who provide HIV testing and counseling to effectively care for themselves as well as their clients;

THEREFORE both governmental (federal, state, and local) and nongovernmental agencies and stakeholders should promote public policies that educate the public about the need for and availability of HIV test counseling for all individuals receiving HIV test counseling regardless of whether the tests are administered in clinical or non-clinical settings or at home;

THEREFORE additional research is needed that focuses on how HIV test counseling contributes to positive health outcomes for those receiving HIV testing and on counseling resources and strategies to address the unique circumstances of in-home HIV testing;

THEREFORE increased funding is needed to: i) ensure access to quality HIV test counseling services for all individuals tested for HIV; ii) provide adequate training programs that draw from psychology to deliver these services; and iii) support research that expands the current evidence base relative to HIV test counseling, including research that addresses the unique challenges associated with ensuring the availability of high quality counseling in the context of in-home HIV testing;

THEREFORE psychology as a discipline will increase its efforts to advocate actively for accessible and quality HIV test counseling for all persons being tested for HIV and will encourage the conduct and publication of research into the health impact and outcomes of HIV testing where test counseling is and is not available.

References

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